These case studies have been modified so as not to identify any actual cases at FIDReC. They are provided for purposes of learning and are not necessarily indicative of outcomes at FIDReC.
Jack fractured his right leg in an accident. As a result, he was hospitalised for treatment. When he filed his hospitalisation claim, the Insurer rejected the claim. The Insurer stated that his claims fell within the scope of an exclusion clause.
It turned out that when Jack applied for the policy, he had declared that he had total knee replacement surgery for his right knee. In view of his medical history, the Insurer did not accept Jack’s application on standard terms. Instead, the Insurer made a counteroffer including a special term excluding any treatment in relation to the right lower limb. Jack signed and accepted the special term, and the policy came into effect.
Jack argued that the current hospitalisation was due to a motor accident and had nothing to do with his previous knee surgery. But, the Insurer maintained that the policy excluded any treatment to the right lower limb. This exclusion was regardless of the reason for the treatment.
Jack filed a case at FIDReC. During the mediation, Jack produced medical memos from his doctor. His doctor stated that the right leg fracture had no relation to his previous knee surgery. The Insurer maintained that it could only pay a claim according to the terms and conditions of the policy. Because the special term excluded treatment relating to the right lower limb, the claim was not payable.
The dispute went for adjudication. The Adjudicator considered the arguments of both parties and found that the exclusion clause was clear. Any treatment to the right lower limb was not covered under the policy. The Insurer’s decision to reject the claim was reasonable. The Adjudicator dismissed Jack’s claim.
Key Learning Points
- Pay particular attention to any terms in the insurance contract when you apply for a policy. Insurers will assess a claim using the policy terms and conditions, including any special terms.
- There are many insurance providers in Singapore. You should approach more than one provider and compare their offered terms before choosing the provider that best suits your needs.
- Be mindful of the documents you are signing. Clarify with your insurer, financial adviser, or a trusted individual should you be unsure of any terms.
- Insurers may place special terms or exclusion clauses on policies at inception based on their assessment of risk. Special terms or exclusion clauses can vary from insurer to insurer.
- When applying for a policy, you may choose to accept or reject the special term at the point of application. You could also try to negotiate or appeal against the special term. However, the terms offered by an insurer are a commercial decision and at the insurer’s discretion.
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